On 10 April 2017 the Commission recommended to the Director of Maritime New Zealand that he inform all New Zealand surveyors and port state control officers about the circumstances of this accident and advise them to pay special attention to any corroded nitrogen cylinders or other pressure vessels when conducting their Class or Flag State surveys, particularly when inspecting pressure vessels stored in an open marine environment.
Issue date:Recommend the fitting of steering limit stops in the installation manual for all HJ-212 jet units, and other model jet units as appropriate.
Issue date:Fit watchkeeping alarms independent of all other equipment in the wheelhouse of all vessels operated by his company and put in place a procedure to ensure that the watchkeeping alarms are operated whenever a navigational watch is undertaken.
Issue date:complete a review of accident and incident notification procedues to ensure notifications, especially those requiring immediate action, are processed in a timely manner.
Issue date:It be a requirement that air transport operators' Operations Manuals and Training Manuals detail their operational and training procedures, minimum experience levels and en route meteorological minima for their Milford Sound operations.
Issue date:Develop a process which, subsequent to a derailment, requires an inspection by qualified wagon maintenance staff of those portions of the train which have not derailed, before the train is authorised to move
Issue date:The trainee controller having to refresh his knowledge in double-line automatic signalling rules at the same time as undergoing desk certification complicated the desk certification process, requiring more handovers during a shift. There would be some safety benefits in KiwiRail’s training system for train controllers in specifying a maximum period for which new and returning train controllers can be away from using critical systems such as double-line automatic signalling before requiring refreshing in these systems.
Issue date:He make all sea staff in his employment aware of the effect the light illuminating the forecastle can have on the ability of other vessels to distinguish the sidelights of their ship at night.
Issue date:You review the flight test requirements for Private Pilot Licence (Helicopter) and Flight Instructor Rating - Helicopter in general and for type ratings on the R22 aircraft in particular to ensure applicants are aware of the hazards of inducing low "g" flight condition in helicopters with teetering rotor systems, and understand the appropriate recovery technique should such a condition be encountered, and are aware of any specific operating hazards which are detailed in the relevant aircraft's Flight Manual.
Issue date:Append a warning note to the Nelson Aerodrome VFG/IFG Chart to the effect that "Gate 5" the north-eastern end of the main apron may be used from time to time for high-power engine runs by medium-weight turboprop aircraft.
Issue date:The Department of Port Administration of the American Samoa Government investigate installation of additional floodlighting on the eastern side of the apron, so that access to aircraft left side doors, lockers and service points is not in shadow.
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